22327 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ed Identification 7 PERhIT NO.
BuildingAddress: f7 a"I f")�J
X&51— 1p c GGWSJG 1/
A A
C /CE 99 nnea57 CITY OF CUPERTINO-BUILDING DIVISION
Con a or.Name: / Lie.N.: APPLICATION /PERMIT
• .� A4 N fiLvYK471 YIU7
Lk.No: gLDINGHA
ELECT UCALPLUMBINC-MLCMCAL CATEGORY ORY CO. OLg
Architect/Englnre
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.. PERMITISSUANCE El El ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat I rollcessed under pruvislonsof Chapter9(comment APPLIANCESRFSIDENIAL JOB DFSCRI ON
Ingwith Section 7000)of DiWsion3ofthe Businemand Pmfe moCode,and my
license is in fu rce and effect PANELS
License Class Lie.tl —UP TO 2DOAHMl
Date CHITECPS DECLARATION 201-1000AMPS
I understand my plum shall be used as public records OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.Fl.
k U(k�uj Licensed Professional SIGNSELFCTRICAL C D 114
G a Fh OWNER-BUILDER DECLARATION SPECWLC]RCNT/MLSC G
E., (hereby affirm that l am exempt from the C Calor.License Taw for the CID �` �] B C
09H following reason.(SMion 7031 Z,Business and Professions Code:Any city or TEMP METER OR POLE INST. vs Y— V G
county which requires permit W construct,alter,improve,demolish,or repair
K 4�,'ca any structure prior to its issuance,also requires the applicant for so ch permit to POWER DEVICES
Ty O U file a signed statement that he b licensed pursuant to the provisiore of the E
Contradors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELEC'T'RIC VALUATION
O elon3ofthe Budnmsand Profewiow Code)orthathe6exem therefromand
f. o the basis for the alleged exemption. Any violation of Section 7071.5 by any OUTLETSES
SWITCFIXTURES H
applicant fora permit subjectsthe applicant to a civil penalty ofnot moreha
tn
QED five hundred dollars(S500). NEW RESIDENTIAL ELECTR
❑I,as owner of the property,or my employees with wages as their sole �'�' STORIES TYPE CONSTRUCTION
s,7 compensation,will do the work and the structure 6 not Intended or offend for
sale(Sec.70K Business and Profetakne;Code:The Contractors License Law
Q does not apply to an owner of property who Wilds or improves thereon,and OCCGRO(P RES UNITS
TLS^ whodoessuchonrkhimselforthwgh hisown employees,provided thatsuch
Improvements am not Intended oroffered formic.If,however,thebuilding or TOTAL:
improvement issold withinoneyearofcompldiogtheowner-W ilderwill have
th,Lkurden of proving that he did not build or improve for purpose ofuls.). QTY. PLUMBING PERMIT FEE FLOOD WNE APN
u L as owner of the Property,am exclusively con lrading with Ilmnaed PERMIT I%
contractors to constrod the project(Sec.7096,Business and ProficZ Code:
The Contractors License law does not apply to an owner of property,who
Wilds or Improves thereon, and who contracts for such JxWjeds with a ALTER-DRAIN&VENT-WATER(EA)
, tt Curia)Bamr.•d Pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ 1 am exempt under Sec. B k P C for thin reason
DRAINS MOOR ROOF,AREA,COND. SANITARY Y_ N
• Owner n abate or RECEIPT Is
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TA% Y N
1 hereby affirm that I have•aoconsent m
rtifite of consent set(Lineare RECEIPT p
certificate of Worken'Cmmpematlanlroura a cenifled copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3gg0,lab C.) '9
Poligtl WC�1CtcA-"-'' RFjCEDING DIV]
Tp
� Cc any riiN7��a�A�ST.'}—'lam cASFn.SYSTEM-OVER a(En)
L ° BDILDINC DI VISION FE CS
F5C !fled copy is hereby famished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
QCen10ed copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEINER-SANffARYSTORM E.A.700FT Date Recei fit
(Chis section need nor be completed if the permit 6 for one hundred dollars
(SIUUJor ICss.) WATER HFATFRW/VENT/ELFCTR ENERGY FEE Y_ N_
I certify that In the performance of the work forwhlch this permit Is blued,
1 shag not employ any person In any manner m as to become mbjed to the WATERSYSTEM/.TREATING
WorkersCompensation Laws of California.Date PAID
ZZ Applicant NEW RESIDENTIALPLMB. SQ.FT. Date Remi IN
Z O NOTICE TO APPLICANT:If,after rvking this Certificate of ExemptbMyou
Fshould become subject tothe Workers'CompCaation prov6iom a(the Labor TOTAL:
cc W Curie,you=at forthwith comply with such provouns orth6 permit shall be BUILDING FEE
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihereby affirm that them 6 a countmction lending agency for the porform TOTAL ELECTRIC FEE
M Z ante of the work for which this permit is issued(Sec.3097,Civ.C.) Fa¢
U O Lender.Name PLUMBING FEE
LL F Lenders Address QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
OW I cenifythatl have read thisapplicetlonand statethat theabove information
d Is correct.T agree to complywith all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>_ 9L
relating to building construction,and hereby authorize representatives ofthis
I— Z city to enter upon the above-mentioned property for inspection purposes. ALIERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cu pert lno Date Recei t#
V against liabilities,jadgments,costs a rad expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
almtuld Cit Inco"naofthegrantingofthispertnit.
� G AIRIiANDWNGUNIT(OVER IO,000CFM) CONSTRUCTION TAX
a
gmtumof Applinnt/Convador Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum building occupant store or handle hazardous HEATING UNIT CIO 100,000 BN) Date Reuel t#
materlalasdefinedby the CuQQgeeeat Munidpa!Code,Chapter 9.17,and the
I Iealth and Safety Code 755374)7 HEATING UNIT(OVER RO,"BTU) TOTAL:
M Yea Na
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RF5ID) ISSUANCE DATE
which emit havrdouaaircon minantsas defined by the Bay Area Air
Qu Iity Management Dist BOILER-COMP DFP OR 100,000 BTU) p�
Yea,�� have read the hazy camus VA materials requirements N
requireents under Chapter 6.95 of BOILER-COMP 1f0,000B ) M
the California Health k Safety Code,Sections 25505,25533 and 75539.I
understand that lithe Wilding does not currently have a tenant,that it 6 my NEW RESIDENTIAL MECH. SQdT F�� egg
maponsibility to notify the occupant of the requirements which most be met
prior an<e of a Certificate of
a 104 9=y
a I o a ent Date TOTAL: ISSUEDBY:
OFFICE COPY